Stress echocardiography is one of the most useful non-invasive diagnostic modalities for detection and evaluation of coronary artery disease (CAD). It is also very useful for assessment of cardiac response to hemodynamic stress in a variety of other cardiac and non-cardiac disorders. Given its cost-effectiveness, stress echocardiography is particularly suited for Indian scenario where the incidence of CAD is rising at an alarming rate and the astronomical expenditure required for its management is borne largely by the patients themselves. However, despite its unequivocal diagnostic value, stress echocardiography remains underutilized, particularly in India, due to the lack of adequate exposure and training in this modality. Unfortunately, while there is extensive literature available to document diagnostic accuracy of stress echocardiography, there are very few texts that actually describe how to perform stress echocardiography in real life. This Indian Academy of Echocardiography guideline document aims to fill this very void. This is a comprehensive 'how to do' document prepared with the objective of providing detailed description of the steps involved in performance and interpretation of stress echocardiography so that there is increased adoption of this important and clinically useful diagnostic modality in daily clinical practice. However, while stress echocardiography has several clinical applications, the present document is restricted to its main application, which is evaluation of CAD.

Introduction: Strain is a unitless measurement of dimensional or deformational change; speckle-tracking echocardiography is the most widely used technique to assess strain, with demonstrated clinical utility in a variety of settings. Objectives: This paper reviews the diagnostic and prognostic impact of echocardiographic assessment of left ventricle myocardial strain and what sonographers need to know in a daily practice. Methods: This paper have the most updated American society of echocardiography recommendations on a speckle tracking strain echocardiography, and included experiences of a large academic center, standardization as well as tips needed to perform a strain in a daily clinical practice. Conclusion: With good feasibility, reproducibility and evidence in support, speckle tracking strain echocardiography can be used as a standard echocardiography parameter in clinical practice.

Objective: To establish normative data for tissue Doppler indices and other parameters for ventricular function assessment in fetal imaging for the Indian population and to assess the variation of these parameters with gestational age. Materials and Methods: A prospective study involving 172 fetuses diagnosed as having normal cardiac structure and function. Mothers were advised for fetal echocardiography for several indications; however, mothers with diabetes (both gestational and pregestational), placental dysfunction, fetuses with intrauterine growth retardation, and multiple gestation were excluded as these could affect the fetal cardiac function despite a normal cardiac structure. Peak myocardial velocity was measured during systole (S'), early diastole (E'), and late diastole (A') using spectral tissue Doppler. Pulsed Doppler was used to measure the inflow early (E) and late (A) diastolic velocities and the diastolic filling period (DFP). M-mode was used to measure the tricuspid and mitral annular peak systolic excursion (TAPSE and MAPSE). Results: Normative data for tissue Doppler velocities and various other parameters for functional assessment of fetal heart were derived from the 172 normal fetuses. On tissue Doppler imaging (TDI), the mean values for the peak systolic and diastolic velocities at the lateral and medial mitral annulus and at the lateral tricuspid annulus and ratio of early and late diastolic velocity (E'/A') increased while the (E/E') ratio decreased with gestational age. Other parameters that increased with age are TAPSE, MAPSE, and the DFP at the tricuspid and mitral valves. The left and right ventricular myocardial performance index did not show any variation with gestation. Conclusion: TDI has already been documented as a useful technique in fetal cardiac imaging. The normative data so derived for various parameters can be used as a future reference. These parameters can prove very useful in fetal cardiac functional evaluation and detection of systolic or diastolic dysfunction at an early stage which may have long-term and prognostic implications.

Takotsubo cardiomyopathy presents as acute heart failure and mimics acute coronary syndrome. It is characterized by transient left ventricular dysfunction in the absence of occlusive coronary disease. Prognosis is generally good with complete recovery of the left ventricle in several weeks. The etiology is unknown and therapy just symptomatic. Death has been described but is rare. This present review gives insights of this important clinical entity.

India is a vast nation with almost 75% of their population living in rural and remote regions. The obvious challenge is in the health-care delivery mechanism because of the disparity in the availability of services and specialists across the region. Therefore, the technology that facilitates the delivery of this essential health care to these remote areas is the need of the hour today. Telemedicine which essentially encompasses exchange of clinical information through a communication media has provided a platform for the delivery of quality health care. Advances in Information and Communication Technology in the area of video-to-video communication have led to the growth of extending the reach of specialist services for diagnostic investigations to areas wherein specialists are unavailable. For a country of over one billion, the number of cardiologists available for even screening patients is abysmally low. Echocardiography is often used to diagnose and exclude important cardiac diagnoses in adults and children. The use of telemedicine in echocardiography is one way to alleviate this problem, wherein a diagnosis can be made through the transmitted images and an appropriate management plan suggested based on the findings before there is patient movement. With the right diagnosis, some of them do not need medical intervention in terms of a procedure or surgery, and they can just be managed by medicines. The convergence of science and technology in our dynamic digital era has resulted in the development of innovative digital health devices that allow easy and accurate characterization in health and disease. Internet of Things (IoT)-assisted medical devices have found immense potential in addressing some of the long-standing issues related to diagnostic tests such as electrocardiogram and echocardiography. These technological advancements and the miniaturization of diagnostic instruments have led to decreasing health-care costs and improving outcomes.

Dynamic left ventricular outflow (LVOT) obstruction has been classically described in patients with hypertrophic cardiomyopathy (HCM). The hypertrophy of the basal septum and systolic anterior motion of the mitral valve leaflet (SAM) cause dynamic LVOT obstruction. In addition, HCM also shows speckled appearance of myocardium and LVOT obstruction is persistent, although to a varying degree. Several other conditions cause the echocardiographic finding of dynamic LVOT obstruction like postoperative patients with hypovolemia, post aortic valve replacement (AVR) or mitral valve repair, hyperdynamic left ventricle and acute anteroapical myocardial infarction. We report two patients who had transient dynamic left ventricular outflow obstruction one with hypertension, mitral valve prolapse associated with hypovolemia and anaemia and another with vomiting and hypovolemia.

Infective endocarditis is an infection of the endocardium of heart and its great vessels. Infective endocarditis if complicated by abscess may lead to severe valvular insufficiency and intractable heart failure. Leaflet abscess although is a very rare complication, but if occurs, leads to increased morbidity and mortality. We report a case of 28-year-old female who had severe mitral valve regurgitation with mitral leaflet abscess confirmed by transesophageal echocardiography. She developed cardiogenic shock, multiple organ dysfunction syndrome with anemia, leukocytosis, thrombocytopenia, liver dysfunction, acute renal failure, and splenic abscess. Due to these multiple comorbid conditions, it could be a very high-risk surgery. Hence, she was managed with medical therapy and responded well.

Echocardiography is pivotal in the evaluation and management of valvular heart disease. Conventionally, echocardiographic assessment of any valve disease is performed at rest. However, as valvular heart disease is a dynamic entity, evaluation only at rest is not sufficient to assess the true hemodynamic severity of the valve lesion. For this reason, stress echocardiography (SE) serves as a useful diagnostic modality. By permitting evaluation under hemodynamic stress, it provides incremental diagnostic and prognostic information which has significant therapeutic implications. Further, exercise SE also permits correlation of the symptoms with the severity of the underlying valve disease. This information is crucial as the development of symptoms is a Class I indication for intervention in valve disorders. These benefits coupled with the easy availability and safety of SE should lead to its more routine application in the management of the patients with valvular heart disease. The present review describes the technical aspects and the clinical utility of SE in the evaluation and management of mitral valve disease.

Cor Triatriatum, otherwise known as triatrial heart, is a rare congenital heart defect. This report describes a case of a 45 yrs old female who was sent to us for evaluation of exertional shortness of breath and swelling of feet. She was found to be in incipient heart failure. Transthoracic echocardiography revealed a membrane separating the right atrium into 2 chambers and dilated Right heart and pulmonary artery with features of pulmonary hypertension. The 2 portions of Right atrium had adequate communication between them, hence her paucity of complications and survival. But perhaps the onset of pulmonary hypertension had aggravated her symptoms forcing her to seek medical attention. Early diagnosis and prompt referral are mandatory to prevent mortality from the defect that is amenable to simple corrective surgery.

Cardiac Amyloidosis (CA) often requires multiple diagnostic modalities with echocardiogram being the most important non-invasive method. Echocardiographic findings of left ventricular hypertrophy (LVH), impaired relaxation and dilated atrias can be seen in others forms of LVH like hypertrophic cardiomyopathy (HCM). Speckle tracking echocardiography (STE), is a relatively new advancement in echocardiography which makes it possible to assess the deformation of the left ventricle and can be utilized for differentiating CA from other forms of LVH. We demonstrate the incremental value provided by STE in distinguishing CA from HCM.

Imaging of the tricuspid valve (TV) by three-dimensional echocardiography (3DE) has not received much attention. 3DE allows users to visualize the whole TV apparatus from any perspective and enables a comprehensive evaluation of the leaflets. This review summarizes the current status of real time 3DE evaluation of TV morphology and function with its potential implications for TV disease assessment, as well as its clinical applications and limitations.

Multimodal imaging of dissecting sinus of valsalva aneurysms from right and left aortic sinuses and its managementKothandam Sivakumar, Vinoth Doraiswamy, Ejaz Ahmed SheriffMay-August 2017, 1(2):167-168DOI:10.4103/jiae.jiae_37_17